Health Insurance KYC Family

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Questions

Step 1 of 8

12%

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First Name(Required)

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Last Name(Required)

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YYYY/MM/DD(Required)

YYYY slash MM slash DD

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Age(Required)

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Gender(Required)

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Mobile Number(Required)

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Email(Required)

Who do you want to be
Covered Under the SHIELD?

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Who do you want to be covered under the shield?(Required)

Myself

Me & My Family

Others

Plans(Required)

PKR
60,000

PKR
100,000

PKR
200,000

PKR
350,000

PKR
500,000

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Click on the desired COVERAGE you need

60,000

100,000

200,000

350,000

500,000

Salamati Plan

Annual Plan Coverage

PKR 350,000

For each family member

Emergency Evacuation

Accidental Emergency Expense

Daily Room and Board

Maternity Coverage

Monthly Premium

PKR 30,000

For 4 family member
The insurance amount for each family member is PKR 6,256 per month

Tahafuz Plan

Annual Plan Coverage

PKR 60,000

For each family member

Emergency Evacuation

Accidental Emergency Expense

Daily Room and Board

Maternity Coverage

Monthly Premium

PKR 30,000

For 4 family member
The insurance amount for each family member is PKR 6,256 per month

Rahat Plan

Annual Plan Coverage

PKR 100,000

For each family member

Emergency Evacuation

Accidental Emergency Expense

Daily Room and Board

Maternity Coverage

Monthly Premium

PKR 30,000

For 4 family member
The insurance amount for each family member is PKR 6,256 per month

Aafiyat Plan

Annual Plan Coverage

PKR 200,000

For each family member

Emergency Evacuation

Accidental Emergency Expense

Daily Room and Board

Maternity Coverage

Monthly Premium

PKR 30,000

For 4 family member
The insurance amount for each family member is PKR 6,256 per month

Rahat Plan

Aaram Plan Coverage

PKR 500,000

For each family member

Emergency Evacuation

Accidental Emergency Expense

Daily Room and Board

Maternity Coverage

Monthly Premium

PKR 30,000

For 4 family member
The insurance amount for each family member is PKR 6,256 per month

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Select Hospital checkbox(Required)

CHILDLIFE FOUNDATION

ZINDAGI TRUST

SAYLANI

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Select Hospital(Required)

CHILDLIFE FOUNDATION

ZINDAGI TRUST

SAYLANI

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Maternity Coverage(Required)

Remove Maternity Coverage

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Maternity Coverage for family(Required)

Remove Maternity Coverage

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I don’t want to contribute(Required)

I don’t want to contribute

PKR

350,000

FOR

1 years

FOR

1 Individual

PKR

60,000

FOR

1 years

FOR

1 Individual

PKR

100,000

FOR

1 years

FOR

1 Individual

PKR

200,000

FOR

1 years

FOR

1 Individual

PKR

500,000

FOR

1 years

FOR

1 Individual

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Gender male

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Gender female

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Gender x

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Add Wife

Please enter a number from 0 to 4.

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Add Husband

Please enter a number from 0 to 1.

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Add son

Please enter a number from 0 to 6.

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Add daughter

Please enter a number from 0 to 6.

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No of Members

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Husband Birthday

YYYY slash MM slash DD

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Wife’s Birthday

YYYY slash MM slash DD

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2nd Wife’s Birthday

YYYY slash MM slash DD

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3rd Wife’s Birthday

YYYY slash MM slash DD

Hidden

4rth Wife’s Birthday

YYYY slash MM slash DD

Hidden

Son’s Birthday

YYYY slash MM slash DD

Hidden

2nd Son’s Birthday

YYYY slash MM slash DD

Hidden

3rd Son’s Birthday

YYYY slash MM slash DD

Hidden

4rth Son’s Birthday

YYYY slash MM slash DD

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5th Son’s Birthday

YYYY slash MM slash DD

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6th Son’s Birthday

YYYY slash MM slash DD

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Daughter's Birthday

YYYY slash MM slash DD

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2nd Daughter's Birthday

YYYY slash MM slash DD

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3rd Daughter's Birthday

YYYY slash MM slash DD

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4rth Daughter's Birthday

YYYY slash MM slash DD

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5th Daughter's Birthday

YYYY slash MM slash DD

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6th Daughter's Birthday

YYYY slash MM slash DD

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Selected Products

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Products Number

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Annual Plan Coverage

Hidden

Maternity Aaram

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Maternity Salamati

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Maternity Aafiyat

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Maternity Rahat

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Maternity Tahafuz

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Aram without Mat

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Aram with Mat

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Salamati without Mat

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Salamati with Mat

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Aafiyat without Mat

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Aafiyat with Mat

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Rahat without Mat

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Rahat with Mat

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Tahafuz without Mat

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Tahafuz with Mat

01 Of 08

Are you or any members of your family presently is in good health?

Self(Required)

Yes

Husband(Required)

Yes

First Wife(Required)

Yes

Second Wife(Required)

Yes

Third Wife(Required)

Yes

Fourth Wife(Required)

Yes

First Son(Required)

Yes

Second Son(Required)

Yes

Third Son(Required)

Yes

Fourth Son(Required)

Yes

Fifth Son(Required)

Yes

Sixth Son(Required)

Yes

First Daughter(Required)

Yes

Second Daughter(Required)

Yes

Third Daughter(Required)

Yes

Fourth Daughter(Required)

Yes

Fifth Daughter(Required)

Yes

Sixth Daughter(Required)

Yes

02 Of 08

Are you or any members of your family presently taking any medication, therapy/treatment?

Self(Required)

Yes

Husband(Required)

Yes

First Wife(Required)

Yes

Second Wife(Required)

Yes

Third Wife(Required)

Yes

Fourth Wife(Required)

Yes

First Son(Required)

Yes

Second Son(Required)

Yes

Third Son(Required)

Yes

Fourth Son(Required)

Yes

Fifth Son(Required)

Yes

Sixth Son(Required)

Yes

First Daughter(Required)

Yes

Second Daughter(Required)

Yes

Third Daughter(Required)

Yes

Fourth Daughter(Required)

Yes

Fifth Daughter(Required)

Yes

Sixth Daughter(Required)

Yes

03 Of 08

Have you or any members of your family ever suffered from any physical or mental illness/ medical ailment (Pre-existing condition) or any deformities?

Self(Required)

Yes

Husband(Required)

Yes

First Wife(Required)

Yes

Second Wife(Required)

Yes

Third Wife(Required)

Yes

Fourth Wife(Required)

Yes

First Son(Required)

Yes

Second Son(Required)

Yes

Third Son(Required)

Yes

Fourth Son(Required)

Yes

Fifth Son(Required)

Yes

Sixth Son(Required)

Yes

First Daughter(Required)

Yes

Second Daughter(Required)

Yes

Third Daughter(Required)

Yes

Fourth Daughter(Required)

Yes

Fifth Daughter(Required)

Yes

Sixth Daughter(Required)

Yes

04 Of 08

Do you or your spouse smoke or consume alcohol?

Self(Required)

Yes

Husband(Required)

Yes

First Wife(Required)

Yes

Second Wife(Required)

Yes

Third Wife(Required)

Yes

Fourth Wife(Required)

Yes

05 Of 08

Have you or your spouse ever in the past or currently are involved in any legal, religious political activities or are you engaged or ever had any involvement in any civil or criminal litigation or police case?

Self(Required)

Yes

Husband(Required)

Yes

First Wife(Required)

Yes

Second Wife(Required)

Yes

Third Wife(Required)

Yes

Fourth Wife(Required)

Yes

06 Of 08

Are you or your spouse employed within the utility sector and engaged in tasks such as handling wiring systems and grid station operations?

Self(Required)

Yes

Husband(Required)

Yes

First Wife(Required)

Yes

Second Wife(Required)

Yes

Third Wife(Required)

Yes

Fourth Wife(Required)

Yes

07 Of 08

Are you or your spouse a domestic/foreign “Politically Exposed Person” (PEP) or a family member/close associate of a domestic/foreign “Politically Exposed Person” (PEP)?

Self(Required)

Yes

Husband(Required)

Yes

Wife(Required)

Yes

Second Wife(Required)

Yes

Third Wife(Required)

Yes

Fourth Wife(Required)

Yes

08 Of 08

Are You pregnant?

Is Your wife pregnant?

Self(Required)

Yes

First Wife(Required)

Yes

Second Wife(Required)

Yes

Third Wife(Required)

Yes

Fourth Wife(Required)

Yes

Questions

Who do you want to be Covered Under the SHIELD?

Salamati Plan

PKR 350,000

PKR 30,000

Tahafuz Plan

PKR 60,000

PKR 30,000

Rahat Plan

PKR 100,000

PKR 30,000

Aafiyat Plan

PKR 200,000

PKR 30,000

Rahat Plan

PKR 500,000

PKR 30,000

350,000

1 years

1 Individual

60,000

1 years

1 Individual

100,000

1 years

1 Individual

200,000

1 years

1 Individual

500,000

1 years

1 Individual

Who do you want to be
Covered Under the SHIELD?